MDS Rejections related to October 2020 Changes

Missouri opted to collect PDPM HIPPS codes on OBRA assessments with an ARD of 10/1/20 or later. This means that SNFs and NFs in Missouri need to complete additional items on OBRA assessments not combined with a Medicare assessment. Additional items include:

  • GG0130 Self-Care items;
  • GG0170 Mobility items;
  • I0020 and I0020B Primary Medical Condition items;
  • J2100 Recent Surgery item. If J2100 is checked yes, J2300-J5000 are to be completed.

Multiple homes have reported their software has not incorporated the additional required items listed above for OBRA comprehensive and Quarterly assessments with an ARD of 10/1/20 or after. They report if they complete the MDS assessments without these items the assessments are rejected by the QIES ASAP system. Some homes report they are able to change a setting in their software themselves that will include these items on OBRA assessments. Some homes report they cannot change the setting in the software themselves, that they must contact their software vendor for this setting change. Most homes that encounter this issue say after their software setting is changed, they must open completely new MDS assessments because the additional items will not be added to the assessment they opened prior to the setting change.

If you are completing an OBRA comprehensive or Quarterly assessment that has an ARD on or after 10/1/20, please ensure the additional items listed above, required to calculate a PDPM HIPPS code, are NOT grayed out in your software. If you discover these items are grayed out, contact your software vendor as soon as possible before continuing with the assessment.

If you have any questions about this issue please contact Stacey Bryan at Stacey.Bryan@health.mo.gov or 573-751-6308. Thank you.

Coding GG0130 Self-Care and GG0170 Mobility items on an OBRA MDS assessment not combined with a Medicare MDS Assessment

This document was created to assist NHs in Missouri with coding GG0130 and GG170 items on OBRA MDS assessments not combined with a Medicare assessment. All of the guidance contained in this document comes from the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual Version 1.17.1.

SNF Patient Driven Payment Model (PDPM) Interrupted Stay Billing Issue

A new issue is affecting some inpatient hospital and Skilled Nursing Facility (SNF) claims when an interrupted stay is billed at the end of the month. The system incorrectly assigns edits U5601-U5608 (overlapping a hospital claim). If you billed the interrupted stay correctly, and your claim is rejected, modify your billing so the claim spans past the last day of the interrupted stay:

  • Bill two months at a time, or
  • Bill a month plus the days in the following month that span the interrupted stay plus 1 day

Adjusting the statement covered from and through dates to encompass the entire interrupted stay will allow your claim to process and pay correctly. Medicare Administrative Contractors will finalize any suspended claims that meet the criteria, so you can make corrections and resubmit your claim.

If we rejected an inpatient hospital claim, the hospital should ask the SNF to modify their claim. Until October 5, a SNF cannot submit an adjustment to a paid claim; they must cancel the paid claim and all subsequent claims in the same stay and resubmit them in sequential order.

CMS will correct the system in the future.

MDS Final Item Sets (Version 1.17.2) for October 1, 2020

In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications. These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1. This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM ones and thereby inform their future payment models.

The changes to the technical data specifications that support these modifications are contained in the Errata v3.00.5 which can be accessed in the file: MDS 3.0 data specs errata (v3.00.5) Final 06-18-2020 in the Downloads section of the MDS 3.0 Technical Information page. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file: MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip, which are also posted in the Downloads section of the MDS 3.0 Technical Information page.

The Department of Social Services (DSS) is required to submit a Medicare Upper Payment Limit (UPL) Demonstration for nursing facilities to CMS at the end of each state fiscal year. Currently, the Missouri nursing facility UPL Demonstration is based on the Medicare Resource Utilization Groups (RUGs) reimbursement system and the associated MDS data. With Medicare’s change in reimbursement to PDPM, CMS has indicated that at some point RUGs calculations will no longer be supported. At that point, or perhaps sooner, the State anticipates transitioning the UPL Demonstration to be based on the PDPM payment methodology that Medicare now uses. DSS will need the additional data items to perform that calculation. This will allow DSS to continue to align the UPL calculation to most closely reflect the Medicare payment methodology. The DSS may also use the additional data for future acuity-based analysis that would require these data elements.

Since Missouri will require the calculation of the PDPM payment codes on the OBRA assessments when not combined with a 5-day SNF PPS assessment, SNFs and NFs in Missouri will need to complete additional items on OBRA assessments when not combined with a 5-day SNF PPS assessment. Additional items include:

  • GG0130 Self-Care items;
  • GG0170 Mobility items;
  • I0020 and I0020B Primary Medical Condition items;
  • J2100 Recent Surgery item. If J2100 is checked yes, J2300-J5000 are to be completed.

Coding instructions for these items on OBRA assessments when not combined with a 5-day SNF PPS assessment will be forthcoming so stay tuned.

Quality Reporting Program: Non-Compliance Letters for FY2021 APU

CMS is providing notifications to SNFs that were determined to be out of compliance with Quality Reporting Program (QRP) requirements for CY 2019, which will affect their FY 2021 Annual Payment Update (APU). Non-compliance notifications are being distributed by the Medicare Administrative Contractors (MACs) and were also placed into facilities’ CASPER folders in QIES on July 13, 2020. Either notification is official notice of non-compliance. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 18, 2020.

If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notice of non-compliance and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.

CMS Answers Frequently asked Medicare Fee-for Service Billing Questions related to the COVID-19

Please see the document found on the CMS Current Emergencies webpage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page under the Billing and Coding Guidance section. Information related exclusively to SNFs can be found on pages 34 and 35 but there may be other pertinent information to SNFs found throughout the document.

SNF Claims Incorrectly Cancelled

From January 26 through February 16, 2020, a software issue caused Skilled Nursing Facility (SNF) claims to be incorrectly cancelled with a message that there was no three day qualifying hospital stay. This issue is corrected. If your claims were incorrectly cancelled, re-bill them in sequential order to receive payment.

Note:

  • Claims need to process in date of service order for each stay for the Variable Per Diem (VPD) to calculate correctly
  • Submit claims in sequence and wait at least 2 weeks before billing subsequent claims
  • Some of the affected claims with older dates of service will require a timely filing exception; enter “Resubmission due to non-qualifying stay” in the remarks field
  • This issue was not caused by the recent implementation of the SNF Patient Driven Payment Model
  • Contact your MAC to receive the Medicare Beneficiary Identifier (MBI) for deceased beneficiaries

MLN Matters Bulletin Revised 3-18 -20 Medicare FFS Respnose to COVID-19

MDS 3.0 RAI Manual – Delayed

March 19, 2020

CMS is delaying the Minimum Data Set (MDS) 3.0 v1.18.1 release, which had been scheduled for October 1, 2020, in response to stakeholder concerns. The MDS item sets are used by Nursing Home and Swing Bed providers to collect and submit patient data to CMS. This MDS data informs payment, quality, and the survey process.

In December of 2019, CMS posted a draft of the MDS 3.0 item set v1.18.0 and received feedback from our stakeholders. We would like to thank the stakeholders for sharing their concerns regarding the proposed changes to the MDS 3.0 item sets and more specifically the removal of the Section G items from OBRA assessments.

The MDS changes CMS planned for October 1, 2020 will now be delayed. CMS staff are actively engaged in discussions with various stakeholders, regarding the various changes, the impacts of these changes, as well as, the compressed timeline to educate and train facility staff and update software and IT systems.

Please direct any comments or questions regarding the above information to MDSCodinganswers@cms.hhs.gov mailbox.

SNF PDPM Claims Issue

CMS recently posted the following on their MLN Connects webpage, which can be found at www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-02-27#_Toc33530674.

Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) initial claims that are processed out of sequence are not paying the correct Variable Per Diem (VPD)-adjusted rate. Also, all adjustment claims are not processing correctly. Claims need to process in date of service order for each stay for the VPD to calculate correctly. We will correct this issue in October. In the interim:

  • Submit claims in sequence by waiting at least 2 weeks before billing subsequent claims;
  • To adjust claims, cancel the initial claim and all subsequent claims in the SNF stay then rebill in sequential order; or, hold adjustments (when allowable) until October when they will process correctly;
  • We encourage you to submit a complete bill at the time of entry.

SSN-based HICN No Longer Accepted on MDS or Medicare Claims

This is a reminder that providers will no longer be able to submit a Social Security Number (SSN)-based Health Insurance Claim Number (HICN) or Railroad Retirement Board (RRB) number on the MDS in item A0600B or on the Medicare claim beginning January 1, 2020. Instead, the Medicare Beneficiary Identifier (MBI) must be used.

For additional details and resources regarding use of the MBI, please refer to the MLN Matters Article to learn how to get and use MBIs.

MDS 3.0 QM (Quality Measurement) Report Updates

The MDS QM reports will be updated to reflect measure updates identified in the MDS 3.0 QM User’s Manual v12.1 available at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html, effective October 1, 2019.

Additionally, the previous SNF QRP Percent of Residents with Pressure Ulcers That are New or Worsened (S002.02) has been added to the MDS QM reports and the MDS Provider Preview and Resident-level Preview Report to allow for continued tracking on this measure.

While being updated, the following reports will not be available from the CASPER system:

  • MDS 3.0 Facility Level Quality Measure Report
  • MDS 3.0 Resident Level Quality Measure Report
  • MDS 3.0 Quality Measure Monthly Comparison Report
  • MDS 3.0 Facility Characteristics Report (add CMS logo, update privacy statement)

Once the report updates have completed, an additional memo will be sent.

If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.

DRAFT version of the 2020 MDS item sets v1.18.0

A new DRAFT version of the 2020 MDS item sets (v1.18.0) has been posted. This version is scheduled to become effective October 1, 2020. Please note that Section G was removed from all Federal item sets.

The files are located in the Downloads section of the MDS 3.0 Technical Information webpage: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html.

MDS PDPM Webinar Series

January 17, 2020 – February 21, 2020: MDS PDPM 6-Week, 6 Session Webinar Series Assessment, Coding & Systems Orientation & Proficiency Series

This 6-week, 6 session webinar series provides MDS section-by-section coding guidance under PDPM and insights for optimal data collection, supportive documentation, and consistent coding accuracy. Live sessions are completed weekly over 6 weeks and review key MDS sections under PDPM. Recordings are provided with full-series purchase for ongoing on-demand access for new hire orientation and as a staff development resource. Reduce the learning curve for clinical reimbursement staff and drive PDPM coding accuracy and compliance with this MDS series taught by Proactive’s expert instructors.

Updated MDS 3.0 Data Specification

On November 8, 2019, CMS posted an updated errata (V3.00.3) to their MDS Technical Information webpage (www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/nhqimds30technicalinformation.html) for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. Two issues were identified. One edit, -3941, will be deleted, and one edit, -3965, will be added. These changes will go into production on December 3, 2019. Once in production, these two changes will be retroactive, applying to all assessments with target dates on or after October 1, 2019.

SNF QRP Threshold Noncompliance Messages

CORMAC used to send out informational messages to SNFs that were not meeting the SNF QRP APU threshold on a quarterly basis ahead of each submission deadline. Swingtech will now send out these messages. If SNFs signed up for these messages with CORMAC they do not need to sign up again, but anybody who newly signs up for these messages will need to send their request to QRPHelp@singtech.com and must include email addresses they wanted these messages to go to along with the facility name and CMS Certification Number (CCN).

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Deadline

The submission deadline for the SNF Quality Reporting Programs (QRP) is approaching. MDS data for April 1 – June 30 (Q2) of calendar year (CY) 2019 are due with this submission deadline. All data must be submitted no later than 11:59 p.m. Pacific Standard Time on November 18, 2019.

As a reminder, it is recommended that providers run applicable CASPER reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

Swingtech sends informational messages to IRFs, LTCHs, and SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

Payroll-Based Journal (PBJ) Deadline

The submission deadline for PBJ is approaching. PBJ data for 7/1/19 through 9/30/19 is due on November 14, 2019. CMS uses PBJ data to determine each facility’s staffing measure on the Nursing Home Compare tool on Medicare.gov website, and calculate the staffing rating used in the Nursing Home Five Star Quality Rating System. Once a facility uploads their data file, they need to check their final Validation Report, which can be accessed in the Certification and Survey Provider Enhanced Reporting (CASPER) folder, to verify that the data was successfully submitted. CMS also strongly recommends that nursing homes run the following CASPER reports to review the accuracy and completeness of the data that they have entered: 1700D Employee Report, 1702D Individual Daily Staffing Report, and/or 1702S Staffing Summary Report. In addition, facilities should be running the MDS Census reports that are also available in CASPER to verify that their census is accurate.

More information about PBJ can be found on the CMS webpage www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.

Updated PDPM DLL Package (V1.0003 FINAL) Available October 7, 2019

A revision to the PDPM DLL Package (V1.0003 FINAL) was posted, and the previous version (V1.0002 FINAL) was removed. This version corrects four bugs that were identified after the V1.0002 release. The package contains updated test files and documentation.

QTSO Memo #2019-065 (dated October 4, 2019) contained information related to issues with version 1.0002 (FINAL) of the PDPM DLL Package, and noted that an updated version would be released today (Monday, October 7, 2019).

Version 1.0003 of the PDPM DLL package is now available on the CMS MDS Webpage at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html.

If you have any questions concerning this information, please do not contact the QTSO Help Desk:

SNF PDPM Assessments and Grouper Update

CMS is aware of issues with the latest PDPM DLL Package (V1.0002 FINAL). We are targeting to release an updated version on Monday, October 7, 2019, which corrects the identified grouper discrepancies.  SNF providers should continue to follow the Resident Assessment Instrument (RAI) requirements which include, but are not limited to, establishing assessment reference dates for OBRA or PPS assessments that are required/scheduled, including the PDPM Transitional Interim Payment Assessments, assessing residents, and coding the applicable MDS assessments.  As per the RAI requirements, assessments should be completed within 14 days and recorded in Z0500. Late submission payment penalties do not apply under the SNF PPS.  We will work with providers to ensure that timely payments are made. We will continue to share updates as they become available. In the meantime, providers should not hesitate to contact us.  For questions regarding PDPM please send inquiries to pdpm@cms.hhs.gov  for information technology questions please send emails to MDSTechIssues@cms.hhs.gov.  Please contact your state Medicaid agency for questions related to the Other State Assessment (OSA) and Medicaid payment.

Error Message 3616b on the MDS 3.0 NH Final Validation Report

CMS posted the following information to their MDS 3.0 Technical Information webpage on 10/2/19:

  • A new version of RUG-IV has been applied to the MDS ASAP system. Effective Sunday, September 29, 2019, the ASAP will evaluate all RUG-IV HIPPS codes using version 1.04. This version is backward compatible and will evaluate assessments with all target dates before or after October 1, 2019. To avoid receiving the ASAP system warning message -3616b, please update the RUG-IV version number to “1.04” to submit your HIPPS code.

Optional State Assessment (OSA)

There is a new item, A0300A Optional State Assessment, that asks “Is this assessment for state payment purposes only?” The State of Missouri is not a case mix state so we do not require the Optional State Assessment (OSA), however, there may be some HMOs or replacement plans which ask you to complete the OSA for payment purposes. You will not submit these OSA assessments to the QIES ASAP system. You must contact the specific HMO or replacement plan to find out what they require.